Inquest into the Death of CHILD RM

Contributing factors

• complex developmental trauma from childhood abuse and neglect
• family and domestic violence exposure
• parental substance use and inability to provide safe care
• severe alcohol-related liver disease and chronic alcohol abuse
• sexual abuse and exploitation
• inadequate post-discharge support following secure care placement
• lack of comprehensive transitional/step-down service for children with complex needs
• limited mental health services for children in care
• insufficient culturally-appropriate and trauma-informed services for Indigenous children
• breach of domestic violence protocols by police
• failure to fully investigate domestic violence indicators on night of death

Coroner's recommendations

1. The Department should consider whether the Children and Community Services Act 2004 WA should be amended to provide for a maximum secure care placement of greater than 42 days.
2. The Department should fast-track implementation of its proposed Complex Community Care service. The current endorsed commencement date of the last quarter of 2023 is manifestly inadequate, as is the accelerated start date of July 2022 currently under consideration. The service must be prioritised and implemented urgently, certainly before the end of 2021, to address the complex needs of young people transitioning from secure care.
3. The Department should, as a matter of urgency, endorse the business case for employment of a cultural therapeutic specialist at the Kath French Secure Care Centre and take all necessary steps to employ this specialist to ensure cultural safety of children and staff and provide staff with access to high-level cultural competence.